Rainbow Center Student Application

AREAS STUDENT NEEDS SPECIAL ASSISTANCE/AIDS: (such as bathroom use, hearing/vision, communication)
MEDICATIONS: (include prescription, over-the-counter; name, dose, and frequency)
Describe abilities/difficulties in the following areas (include assistance required or equipment needed). Please feel free to attach a separate sheet of paper if more space is needed in your description for any of the areas listed below:
PHYSICAL FUNCTION: (i.e., Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
Ability to Maintain Balance for 30 minutes:
Ability to Maintain Balance for 45 minutes:
PSYCHO/SOCIAL FUNCTION: (i.e., Work/school including grade completed, leisure interests, relationships- family structure, support systems, companion animals, fears/concerns, etc.)
GOALS: (i.e. Why are you applying for participation? What would you like to accomplish?)
ADDITIONAL NOTES/COMMENTS:
Signature

Clear
Date:

MonthDayYear
Date
Relationship to Student
DODO NOT
Consent to and authorize the use and reproduction by Rainbow of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, and exhibition or for any other use for the benefit of the program.
Signature

Clear
Date:

MonthDayYear
Date
Client/Parent or Legal Guardian

Authorization for Emergency Medical Treatment Form

'
ParticipantStaffVolunteer
Name:

First NameLast Name
DOB:

MonthDayYear
Date
Phone:
Format: (000) 000-0000.
Relevant medical information:
In the event of an emergency, contact:
Name:

First NameLast Name
Relation:
Phone:
Format: (000) 000-0000.
Name:

First NameLast Name
Relation:
Phone:
Format: (000) 000-0000.
Name:

First NameLast Name
Relation:
Phone:
Format: (000) 000-0000.
Medical Consent

Please read carefully before you select either option
I authorize Rainbow to 1. Secure and retain medical treatment and transportation if needed and 2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. Parent or legal guardian will remain on-site at all times during equine assisted-activities.
Consent Plan

Please sign and date this option only if you have AUTHORIZED emergency treatment to be given above
This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person(s) above is/are unable to be reached.
Date:

MonthDayYear
Date
Consent Signature:

Clear
Client, Parent, or Legal Guardian
Non-Consent Plan

Please select this option only if you DO NOT AUTHORIZE emergency treatment to be given and have selected that option above
In the event emergency treatment/aid is required, I wish the following steps to take place:
Date:

MonthDayYear
Date
Non-Consent Signature:

Clear
Client, Parent, or Legal Guardian

Rainbow Scheduling Request Form
Participant's Name
Parent / Guardian Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Availability
Please indicate 1^st, the 2^nd, and 3^rd preferred times that you would be available to attend by marking appropriate boxes.

Availability Please indicate 1ˢᵗ, the 2ⁿᵈ, and 3ʳᵈ preferred times that you would be available to attend by marking appropriate boxes.

Rows	Tuesday	Wednesday	Thursday	Friday	Saturday
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00

***No shows or late cancellations (less than 12 hours) will be charged the rate of a lesson $76.00***

VIRGINIA EQUINE ACTIVITY LIABILITY ACT
As Amended 2003
Section 3.1-796.130. Definitions
As used in this chapter, unless the context requires a different meaning:
"Engages in an equine activity" means (i) any person, whether mounted or unmounted, who rides, handles, trains, drives, assists in providing medical or therapeutic treatment of, or is a passenger upon an equine, (ii) any person who participates in an equine activity but does not necessarily ride, handle, train, drive or ride as a passenger upon an equine (iii) any person visiting, touring or utilizing an equine facility as part of an event or activity, or (iv) any person who assists a participant or equine activity sponsor or management in an equine activity. The term "engages in an equine activity" doe not include being a spectator at an equine activity, except in cases where the spectator places himself in an unauthorized area and in immediate proximity to an equine or equine activity.
"Equine" means a horse, pony, mule, donkey, or hinny.
"Equine activity" means (i) equine shows, fairs, competitions, performance, or parades that involve any or all breeds of equines and any of the equine disciplines, including, but not limited to dressage, hunter and jumper horse shows, grand prix jumping, three-day events, combined training, rodeos, driving, pulling, cutting, polo, steeple chasing, endurance trail riding and western games, and hunting; (ii) equine training or teaching activities; (iii) boarding equines; (iv)riding, inspecting, or evaluating an equine belonging to another whether or not the owner has received some monetary consideration or other thing of value for the use of the equine or is permitting a prospective purchaser of the equine to ride, inspect, or evaluate the equine; (v) rides, trips, hunts, or other equine activities of any type however informal or impromptu that are sponsored by an equine activity sponsor; (vi) conducting general hoof care, including but not limited to placing or replacing horseshoes or hoof trimming of an equine and (vii) providing or assisting in breeding or therapeutic veterinary treatment.
"Equine activity sponsor" means any person or his agent who, for profit or not for profit, sponsors, organizes, or provides the facilities for an equine activity, including but not limited to pony clubs, 4-H clubs, hunt clubs, riding clubs, school-and college-sponsored classes and programs, therapeutic riding programs, and operators, instructors, and promoters of equine facilities, including but not limited to stables, clubhouses, pony ride strings, fairs, and arenas at which the activity is held.
"Equine professional" means a person or his agent engaged for compensation in (i) instructing a participant or renting to a participant an equine for the purpose of riding, driving, or being a passenger upon an equine or (ii) renting equipment or tack to a participant.
"Intrinsic dangers of equine activities" means those dangers or conditions that are an integral part of equine activities, including but not limited to (i) the propensity of equines to behave in ways that may result in injury, harm or death to persons on or around them; the unpredictability of an equine's reaction to such things as sounds, sudden movement, and unfamiliar objects, person, or other animals (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential of a participant acting in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the equine or not acting within the participant's ability.
Please Initial

"Participant" means any person, whether amateur or professional, who engages in an equine activity, whether
or not a fee is paid to participate in the equine activity.
Section 3.1-796.132. Liability limited; liability actions prohibited.
A. Except as provided in Section 3.1-796.133, an equine activity sponsor, an equine professional, or any
other person, which shall include a corporation, partnership, or limited liability company,
B. shall not be liable for an injury to or death of a participant resulting from the intrinsic dangers of
equine activities, and except as provided in Section 3.1-796.133, no participant nor any participant's parent,
guardian or representative shall have or make any claim against or recovery from any equine activity sponsor,
equine professional, or any other person for injury, loss, damage, or death of the participant resulting from
any of the intrinsic dangers of equine activities.
C. Except as provided in Section 3.1-796.133, no participant or parent or guardian of a participant who has
knowingly executed a waiver of his rights to sue or agrees to assume all risks specifically enumerated under
this subsection may maintain an action against or recover from an equine activity sponsor or an equine
professional for an injury to or death of a participant engaged in an equine activity. The waiver shall give
notice to the participant of the intrinsic dangers of equine activities. The waiver shall remain valid unless
expressly revoked in writing by the participant or parent or guardian of a minor.
Section 3.1-796.133. Liability of equine activity sponsors and equine professionals.
No provision of this chapter shall prevent or limit the liability of an equine activity sponsor or equine
professional or any other person who:
1. Intentionally injures the participant;
2. Commits an act or omission that constitutes negligence for the safety of the participant, and such act
or omission caused the injury, unless such participant, parent, or guardian has expressly assumed the risk
causing the injury in accordance with subsection B of Section 3.1-796.132; or
3. Knowingly provides faulty equipment or tack, and such equipment or tack was faulty to the extent
that it did cause the injury or death of the participant.
HISTORY: Approved by the Governor on March 22, 2003
If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
Rider
Parent or Guardian*
Printed Name
Printed Name
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Parent or Guardian*
Printed Name
Date

MonthDayYear
Date
*PARENT OR GUARDIAN MUST SIGN IN ADDITION TO RIDER UNDER EIGHTEEN YEARS OF AGE
BOTH PARENTS WITH LEGAL CUSTODY OF A MINOR MUST SIGN

Release, Waiver & Indemnity Agreement
The undersigned (hereinafter referred to as "rider"), being of legal age or signing in conjunction with a parent or legal guardian if not of legal age, desires to enter upon the premises known as the Rainbow Therapeutic Riding Center, 16198 Silver Lake Rd., Haymarket, Virginia and/or to use horses and or facilities either owned or controlled by Rainbow Therapeutic Riding Center., and/or to receive training or instruction from the agents, volunteers or employees of Rainbow Therapeutic Riding Center., and being fully aware of the risk of injury and dangers inherent in entering upon said premises and/or the riding and handling of horses, hereby elects voluntarily to enter upon said premises and/or to participate in said activities and does hereby willingly enter into this Release, Waiver & Indemnity Agreement.
Therefore, in consideration of being permitted to enter the premises known as Rainbow Therapeutic Riding Center, and/or receive instruction or assistance from the agents, volunteers, or employees of Rainbow Therapeutic Riding Center. The rider knows and expressly waives Rider's rights to sue Rainbow Therapeutic Riding Center. Its officers, directors, volunteers, employees, agents, successors, heirs, and assigns; for any injury, death, loss, or damage caused to Rider or to Rider's property, and Rider agrees to assume all risks inherent in riding or otherwise coming in contact with horses, including, without limitation, the risks of injury, death, loss, or damage to Rider or to Rider's property. Rider acknowledges that Rider has been given notice of the risks inherent in and intrinsic dangers of equine activities, including (i) the propensity of an equine to behave in dangerous ways which may result in injury, harm, or death to persons on or around them; (ii) the unpredictability of an equine's reaction to such things as sounds, sudden movement, unfamiliar objects, persons, or other animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential of a participant acting in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the equine or not acting within the participant's ability, and Rider expressly agrees to assume all such risks and waives all rights to sue for injuries caused by such risks. This waiver and express assumption of risks shall specifically apply to Rider and to any and all minor children and/or wards of Rider, in accordance with the terms of VA code ann.§§3.1-796.130 et seq.(chapter 27.5, code of Va. (1950)).
If Rider is a minor or otherwise under a legal disability, this agreement shall be signed by Rider's parent or legal guardian. By signing, the parent or legal guardian agrees (i) to waive the parent's, guardian's, and Rider's rights to sue the parties named in the immediately preceding paragraph; (ii) to assume, on behalf of the parent, guardian, and Rider, the risks set forth in the immediately preceding paragraph, in addition to all other risks of riding or otherwise coming into contact with horses; and (iii) to indemnify and hold harmless Rainbow Therapeutic Riding Center, its officers, directors, volunteers, employees, agents, successors, heirs, and assigns; from any loss, claim, suit or judgment resulting from any injury, death, loss or damage sustained or claimed by Rider (or Rider's personal representative), and further to indemnity Rainbow Therapeutic Riding Center. Its officer's directors, volunteers, employees, agents, successors, heirs, and assigns from any and all costs of defending such claims, including attorneys' fees.
It is expressly agreed by Rider and any parent or guardian whose signature appears on this document that this Release, Waiver, and Indemnity Agreement shall be governed and construed as being sufficient to satisfy the assumption of risk and waiver requirements necessary to relieve equine activity sponsors and equine professionals from liability under the Virginia Equine Activity Liability Act, and that Rainbow Therapeutic Riding Center its Board of Directors, volunteers and employees; by the provisions of that Act. This Release, Waiver, and Indemnity Agreement shall be governed and construed by the laws of the Commonwealth of Virginia, regardless of where any injury or loss shall occur. In the event that any portion of this Release, Waiver, and Indemnity Agreement shall be declared unenforceable, such declaration shall not affect the remaining terms of this document, which shall survive intact.

Rider has been advised to wear protective headgear and hard-soled, heeled footwear at all times while riding or otherwise coming in contact with horses and expressly assumes the risks of injury resulting from failure to do so and/or from selecting headgear or footwear which does not adequately protect against injury.
CAUTION: READ BEFORE SIGNING
Rider
Parent or Guardian*
Printed Name
Printed Name
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Parent or Guardian*
Printed Name
Date

MonthDayYear
Date
*PARENT OR GUARDIAN MUST SIGN IN ADDITION TO RIDER UNDER EIGHTEEN YEARS OF AGE BOTH PARENTS WITH LEGAL CUSTODY OF A MINOR MUST SIGN

Dear Rainbow Parents and Students,
We are very excited to have you and your students here at Rainbow. Below is information to help our sessions run smoothly and maximize your riding experience. Please read through them carefully and let us know if you have any questions.
- Please dress appropriately for riding: Long pants and close-toed shoes (a shoe with a heel is preferred for safety measures). No scarves or loose, floppy clothing. Students cannot ride in shorts.
- A $35.00 administrative fee will be billed at the beginning of each year.
- Makeups will only be available for one (1) missed lesson during the 10-week session. If Rainbow cancels, the lesson will be made up. No shows do not receive a makeup. Makeups canceled less than 24 hours in advance forfeit that makeup. Makeups may only be rescheduled one (1) time.
- Cancellations with less than 12 hour notice will be charged the rate of a lesson ($76). We depend on our wonderful volunteers to help get horses ready, side walk, and horse lead. Some come from as far as Alexandria to help with your riders' lessons and last minute cancellations or no-shows mean their time has been spent coming to Rainbow and not being needed.
- Students with 2 no-shows forfeit their spot in the program.
- Lesson semesters run in 10-week increments. All lesson payments are due upon receipt of the invoice. If a payment plan needs to be arranged, please contact Robin Firestone at rainbow@rainbowriding.org.
- Please arrive 10 mins before the lesson starts!
- Be sure your rider has had a snack, is well hydrated, and has used the restroom before the lesson starts.
- Not all lessons will include riding! Horsemanship begins on the ground by forming a relationship with the horse. Please understand that groundwork, grooming, and in-hand work are extremely important for the therapy process. If a session is not mounted, your instructor is very open to explaining the goals and objectives for the groundwork that was done.
- Please respect the one-on-one aspect of lessons and allow students space to focus on their lesson.
- Horse selection may change without notice.
- If a mounted lesson ends prematurely due to weather or student/equine behavior issues, the instructors will have a modified lesson plan.
- Rainbow recommends that participants avoid wearing non-silicone or non-breakable rings during equine activities, as well as dangling necklaces/bracelets. Rings and other dangling jewelry can potentially get caught and result in significant injury. If a participant chooses to wear rings or other potentially hazardous jewelry, they have acknowledged the inherent risk in doing so.
- Applications need to be updated on an annual basis. This ensures that instructors are updated with significant changes in health status, medications, and behavior issues. If you have found a behavioral intervention beneficial, please share it with your instructors so they can help their riders get the most out of their lessons.
- Rainbow requires that parents/guardians remain on the property of Rainbow for the duration of the lesson for participants who experience conditions with potentially severe symptoms.
- If your student experiences seizures, the program director will discuss Rainbow's seizure policy with you to ensure the safety of your student and their team.
- Rainbow reserves the right to refuse service when activity is unsafe for participant, volunteer, equine, and staff.
Thank you again for choosing Rainbow as your therapeutic riding facility.
Please sign and return to Rainbow.
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Rainbow Center Application

General Information:

Health History:

Authorization for Emergency Medical Treatment Form

In the event of an emergency, contact:

Medical Consent

Consent Plan

Non-Consent Plan

Rainbow Scheduling Request Form

Availability

VIRGINIA EQUINE ACTIVITY LIABILITY ACT

Section 3.1-796.130. Definitions

Section 3.1-796.132. Liability limited; liability actions prohibited.

Section 3.1-796.133. Liability of equine activity sponsors and equine professionals.

Release, Waiver & Indemnity Agreement

Dear Rainbow Parents and Students,